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HomeMy WebLinkAbout1460DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -2 -4.9 BOX 13 IgzE 1 IN :?Y.,, 01460 '-� C4 &--1 PUTNAM COUNTY DEPARTMENT OF H DIVISION OF ENVIRONMENTAL HEALTH 3 CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR SEWAGE TREATMENT SYSTEM PCHD CONSTRUCTION PERMIT # 38 Located at ryJff0P0 e0- 7'2-,4/L' '2-,4 i L Town or Village PR Owner /Applicant Name loop -lw m ry L u= Tax Map 34 Block Z- Lot Formerly '"" Subdivision Name 4I '4A '4T6-W h-&cC Subd. Lot # Mailing Address 1540 vr66YIlf44tLx -sr, yo2/Cgowv► /- Jei4h1S / _Zip /aS Date Construction Permit Issued by PCHD Separate Sewerage System built by �Oy 'rk /4 it C_ Cd O' f- Address P6, f j)g 3 11 (ghy Consisting of Gallon Septic Tank and :5'00 1r 2 f=l jj Tj ,tr-H 6 Other Requirements: Water Suouly: Public Supply From Address or: Private Supply Drilled by- d4ci,� Address Eatt"-e':S Building Type C010P7 t 6L- Has erosion control been completed? N Number of Bedrooms Has garbage grinder been installed? /x-J a I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as- built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved plans and the standards, rules and regulations PutnwA County Department of Health. Date: L-4112- Certified by Vt. P.E. ✓ R.A. e n P of, sional) ,_ Address Po Box Ts-o , M440 C /� / License # Any person occupying premises served by the above system(s) shall promptly take such action as may be necessary to secure the correction of any unsanitary conditions resulting from such usage. Approval of the separate sewage treatment system shall become null and void as soon as a public sanitary sewer becomes available and the approval of the private water supply shall become null and void when a public water supply becomes available. Such approvals are subject to modification or change when, in the judgment of the Director /Commissioner, such revocation, modification or change is necessary. B ,Title: �� Date: i Fcopy2--HU File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional Form CC -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES rW WELL COMPLETION REPORT "11N f ma y ., Well Location Street Add s: / . Inn, TownNillage: Tax Map # Map Block Lots) Well Owner: Name: Address: 61 r Use of Well: 1- Primary 2- Secondary _Residential U _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring _Other(specify) Industrial Institutional Standby Drilling Equipment _Rotary _Cable percussion Xcompressed air percussion Other(specify) Well Type Screened _Open end casing I Open hole in bedrock Other Casing Details Total Length gLft. Length below gradeVft. Diameter in. Weight per foot /71b/ft Materials: Steel Plastic Other Joints: Welded ' Threaded Other Seal: Cement grout Bentonite Other Drive shoe: Yes _ No Liner: _Yes KNo Screen Details Diameter (in) Slot Size Length ft Dept to Screen Developed? First _Yes No Hours Second Well Yield Test _Bailed _Pumped A Compressed Air Hours A lYield - gpm - Depth Date Measure from land surface - static (specify 63 'ec During yield test ft) "-M, Depth of completed Well in Well Log If more detailed information...... _ -- . descriptions or sieve analyses are available, please attach. Depth From Surface Water Bearing Well in Formation Description ft. ft. Land surface . ..___..._... If yield was tested at different depths during drilling list: Feet Gallons Per Minute Pump /Storage Tank Information Pump Type Capacity . Depth Model � X07 Voltage HP Tank Type Volu D�te� ':e�`II.0 ,�plete�l� .., 1r!VeIGQ�flller ,,rl�p ;sialler'PGi'r(fipat?df PC=C rii�catel� �,�_ �.. ><:• ` ......... ��� NlY- State�#�' k° x N� � ° ; Nk XI+1Kate x ; #�r Qe,��e� :Rep rt �� °` _ 3 w�i:: ' kK -.} ){ #� _ # 1: � '� �S k � ki 1tn F ax#•�� f �1i . �'"+Y�i� uim Instal epllame�7kaWRY K 3CYN k b %kYA k t L X Y i ` di k p0: S .4 ". �'� ' """' _ #. -..,, e'.^_. r NOTE: Exact Location oVell with distances to at least two permanent landmarks to b &provided on a separate she plan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 N 00, ,.ASB6lLr LAIDUT DIME/-4S/0qa;, 1% 1. -rcri-ft -re.,f-,4cq LE-441,1Y. 19::o PurrNAM COUNTY DEPARTMENT OP HEALTH DIVISION OfiENVI , ONIVIENTAI HEAITHSERVICES.. IT 9L];. � -0 , - , 2- APPROMED A.,') NOTED FOP, GKFOR�!'2)11A/N�CE WIT H APPLICABLE: R I UES AND REGULAMNS OF THE ` v � � O y .. O b ,>6c3 ILA LA lou`- zi s. a a t�t'�IS /5 TG GEQTIF TF�C Rem q►�� Rai WaTc: TH�s �}S6ul[,'f BaS GfOVS.u� Of_ n i a t�t'�IS /5 TG GEQTIF TF�C Rem q►�� Rai WaTc: TH�s �}S6ul[,'f BaS GfOVS.u� Of_ n PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES `Well' Perin# :ter �) r'Yx `�r .? r WELL COMPLETION REPORT ore Well Location Street Add s: 39 76 7% j Town/Village: A Tax Map # Map � Block 2– Lots) GPS Well Owner: Name: ress: Ins � �4w Use of Well: 1- Primary 2- Secondary _Residential _Public Supply Air cond /heat pump _Irrigation Business Farm Test/monitoring —Other(specify) Industrial Institutional Standby Drilling Equipment Rotary _Cable percussion Compressed air percussion _Other(specify) Well Type _Screened _Open end casing I Open hole in bedrock _Other Casing Details Total Length ,,U ft. Length below gradeZft. Diameter -in. Weight per foot 1b /ft Materials: Steel Plastic Other Joints: Welded Threaded Other Seal: Cement grout Bentonite Other Drive shoe: Yes _ No Liner: _Yes No Screen Details Diameter (in) Slot Size Length ft Dept to Screen t Develo ed? First I ]Hours _Yes _No Second I I I Well Yield Test _Bailed _Pumped Compressed Air Hours Yield gpm Depth Date Measure from an surface-static (speci ft 63 'Ee During Re test ft . bi, A'6 Dept o complete we m it I S-0 Well Log If more detailed information descriptions -or sieve analyses are available, please attach. Depth From Surface Water Bearing Well Diameter in Formation Description ft. ft. Land Surface If yield was tested Feet Gallons Per Minute Pump /Storage Tank Information at different depths Pump T pe Capacity during drilling Depth Q Model list: Voltage HP Tank Type tt' d,1b!l Volu NOTE: Exact Location oVell with distances to at least two permanent landmarks to to provided on a separate sherplan. White copy: HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller Form WC -97 Rev. 3/06 SHERLITA AMLER, MD, MS, FAAP Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health L,,ty P OWNER'S NAME: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 E911 ADDRESS VERIFICATION FORM Nc* TAX MAP NUMBER: E911 ADDRESS: TOWN: t .AUTHORIZED. TOWN OFFICIAL: (Signature) DATE:3 ©� C C-- ROBERT J. BONDI County Executive ROBERT MORRIS, PE Director of Environmental Health The Putnam County Department of Health will not issue a Certificate of Construction Compliance unless the above form is completed, i.e., a legal E911 address is assigned by an authorized town official. This form is to be submitted with the application for a Certificate of Construction Compliance. E91 1 addressverificati3n - Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Water Supply Section (845) 225 -5186 Fax (845) 225 -5418 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES GUARANTEE OF SUBSURFACE SEWAGE TREATMENT SYSTEM 1 4di -A C'ovn`7-y .. Hames Owner or Purchaser of Building M.Ofzm '01 Building Constructed by Tax Map Block Lot Town/Village 31 -�I eod ©rye 7,-rr,,,.1 64_aMatol ' A-690 -c Location - Street Subdivision Name Cat nr/}L Building Type . Subdivision Lot #- I represent that I am wholly and completely responsible for the location, workmanship, material, construction and drainage of the sewage treatment system serving the above- described property, and that is has been constructed as shown on the approved plan or approved amendment thereto, and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition any part of said system constructed by me which fails to operate for a period of two years immediately following the date of approval of the "Certificate of Construction Compliance" for the sewage treatment system, or any repairs made by me to such system, except where the failure to operate properly is caused by the willful or negligent act of the occupant of the building utilizing the The undersigned further agrees to accept as conclusive the determination of the Public Health Director of the Putnam County Department of Health as to whether or not the failure of the system to operate was caused by the willful or negligent act of the occupant of t e building utilizing the system. D ted: Month_ Day Year / 2— Signature: Title: Pr, S (Owner) - Signature U Corporation Name (if pc' oration) Address: so l �h State _ `,�'. Zip lfi�+ -c �c, •'1 S lac tX-1 i Corporation Name (if corporation) Address:. 3 ((L( �nix` Jk State Zip Form GS -97 YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown )Hei9,-zts, N.Y. 10598 1914) 245 -2800 Albert H. Padov'ani, Di'rec or;- ** TEST REPORT ** LAB #: 1.203326 CLIENT #: 6471 NON STAT PROC PAGE: 1 of 2 -------------------------------- ~ ---- --------,-------»----------- w----------------- a------ - - - - -- NORTH COUNTY HOMES 156 TOMAHAWK ST YORKTOWN HGTS, NY 10598 DATE /TIME TAKEN: 08/22/12 04:00 DATE /TIME RECD: 08/22/12 04:38 REPORT DATE: 08/28/12 PHONE: (914)- 447 -8780 SAMPLING SITE i L� : 11, THEODORE `TRAIL's�' PATTERSON, NY WELL TANK SAMPLE TYPE..: PRESERVATIVES: POTABLE HNO3 COLD BY: JOE FESTO TEMPERATURE..: < 4C NOTES ...: ---------------------------------------------------------------------------------------f--------- COLIFORM METH: MF . .:. -t,,,. ; START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD PUTNAM CNTY PROFILE 08/23/12 0400 08/24/12 0400 MF T. COLIFOR ABSENT /100 ML ABSENT SM 18 -20 9222B 08/27/12 LEAD (IMS) 1.0 ppb 0 -15 ppb SM 18 -19 3113B 08/24/12 0655 08/24/12 0425 NITRATE NITRO 1.51 MG /L 0 - 10 SM18- 20450ONO3 08/24/12 0325 08/24/12 0350 NITRITE NITRO 0.01 MG /L 1.0 MG /L SM18- 20450ONO2 08/23/12 IRON (Fe) <0.06 MG /L 0 -0.3 mg /l SM 18 -20 3111B 08/23/12 MANGANESE (Mn 0.07 MG /L 0 -0.3 mg /l SM 18 -20 3111B 08/27/12 SODIUM (Na) 37..29 MG /L N/A SM 18 -20 3111B 08/23/12 1110 08/23/12 1113 * pH 7.4 UNITS 6.5 -8.5 SM18 -20 4500HB 08/24/12 HARDNESS,TOTA 250 MG /L N/A SM 18 -20 2340C 08/27/12 ALKALINITY (A 178 MG /L N/A SM 18 -20 2320B 08/22/12 0500 08/22/12 0501 TURBIDITY (TU <1 NTU 0 -5 NTU SM 18 (2130B) COMMENTS: MFTC ota Coliform = This result indicates that the water (was), (was not) of a satisfactory sanitary quality according to ew York State and EPA federal drinking water standard for this parameter. This comment applies to the Total Coliform test only. Pb /Cu LEAD limits for public schools are set at,15 ppb. EPA Lead,& Copper Rule for Public Systems requires that no more than i0% of their distribution points have a LEAD value of more than 15,ppb and a COPPER value of 1.3 mg /L, else water treatment must be undertaken to reduce the waters corrosive potential. Fe /Mn If both iron and manganese are present, their total value combined shall not exceed 0.5 mg /L. IMS = IMMEDIATE METAL SAMPLE.(INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINIMUM OF 6 HOURS OR OVERNIGHT) NMS = NORMAL METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER RUNNING FOR 10 715 MINUTES MINIMUM) YML ENVIRONMENTAL SERVICES 321 Kear Street Yorktown kei44its, N.Y. 10598 (914) 245 -2800 - Albert•: -H. r—a ovani, D iregtor. .. .. . ** TEST REPORT ** LAB #: 1.203326 CLIENT #: 6471 NON STAT PROC PAGE: 2 of 2 NORTH COUNTY HOMES 156 TOMAHAWK ST YORKTOWN HGTS, NY 10598 DATE /TIME TAKEN: 08/22/12 04:00 DATE /TIME RECD: 08/22/12 04:38 REPORT DATE: 08/28/12 PHONE: (914)- 447 -8780 SAMPLING SITE: LOT 4, THEODORE TRAIL, PATTERSON, NY SAMPLE TYPE..: POTABLE : WELL TANK PRESERVATIVES: HNO3 COLD BY: JOE FESTO TEMPERATURE..: < 4C NOTES...: COLIFORM METH:.MF START DATE /TIME END DATE /TIME FLAG PROCEDURE RESULT NORMAL - RANGE METHOD Na No limits for Sodium are proscribed. Suggested guidelines state that for people on a sodium restricted diet,the water should contain no more than 20 mg /L of Sodium. For those on a moderately restricted diet, a maximum of 270 mg /L of Sodium is suggested. * pH pH SCALE IN WATER RANGES FROM 1 -14. MEASUREMENT OF pH IS ONE OF THE IMPORTANT AND FREQUENTLY USED TESTS IN WATER CHEMISTRY. WATER WITH A LOW pH MIGHT BE CORROSIVE TO METAL PIPES AND FIXTURES. THE'NORMAL RANGE OF pH IS 6.5 TO 8.5. pH IS A FIELD MEASUREMENT AND IS TESTED OUTSIDE THE HOLDING TIME. pH REPORTED FOR REFERENCE ONLY. Hd TOTAL HARDNESS IS DEFINED AS THE SUM OF THE CALCIUM & MAGNESIUM CONCENTRATION, BOTH EXPRESSED AS CALCIUM CARBONATE, IN MG /L. THE HARDNESS MAY RANGE FROM 0 TO HUNDREDS OF MG /L, DEPENDS ON THE SOURCE AND TREATMENT TO WHICH THE WATER HAS BEEN SUBJECTED. SOFT WATER: 0 -70 MG /L VERY HARD WATER: ABOVE 300 MG /L MODERATELY HARD WATER: 70 -140 MG /L MG /L = MILLIGRAM PER LITER HARD WATER: 140 -300 MG /L (1 grain /gallon = 17.2 MG /L) ALK (ALKALINITY REPORTED AT pH 4.5) IMS IMS = IMMEDIATE METAL SAMPLE. (INTERPRETATION: WATER SAMPLED AFTER SITTING UNDISTURBED A MINUMUM OF 6 HOURS OR OVERNIGHT) THE ABOVE TEST PROCEDURES MEET ALL REQUIREMENTS OF NELAC, AND RELAT LY T H SAMPLES RECEIVED BY THE LAB SUBMITTED BY. V' Alber .adovani, M.T.(ASCP) Director ELAP# 10323 PUTNAM COUNTY HEALTH DEPARTMENT LICENSED SEPTIC SYSTEM CONTRACTOR License # 1227 The contractor listed on the back of this card is duly licensed Expires on: January 17, 2013 Licensee Name Anthony Lupmacci f. Business Name & Address South Lane Construction Inc. PO Box 344 Amawalic, NY 16509 kkAny questions call I. Putnam County Health Department 845-808-1390 ALLEN BEALS, M.D., J.D. Commissioner of Health Director of Environmental Health September 18, 2012 Roy Fredriksen, P.E. PO Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH I Geneva Road, Brdwster, New York 10509 Phone # (845) 808-1390 Fax # (845) 278-7921 MARYELLEN ODELL County Executive Re: Construction Compliance — North County Homes 38 Theodore Trail (T) Patterson, TM 34-2-49 This office has received and reviewed the most recent set of plans for the above-mentioned project. We would like to offer the following comment for your review and consideration. • The as-built location for the well has not been provided. This office will continue its review. upon consideration of the above-mentioned comments. yq Very truly yours, fDh ( S. P osep aravati, Jr., PE Assistant Public Health Engineer JSP:cw ALLEN DEALS, M.D., J.D. MARYELLEN OD&.,L Commissioner of Iieattii * County Executive ROBERT MORRM P.E. D#octprofEnvkmmienialtIealxl► DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Telephone: (845) 808 -1390; Fax: (845) 278 -7921 September 10, 2012 Roy Fredriksen, P.E. PO Box 950 Mahopac, NY 10541 Re: Field Inspection — SMG & Gramatan Assoc. Theodore Trail (T) Patterson, TM 34. -2 -49 Dear Mr. Fredriksen: A re- inspection.at the above referenced lot has been completed.. There are no further comments to be addressedat this time in reference to this Department's open work inspection. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw r u lAAM C:U UNTY DEPARTMENT OF EEALT'H D"10N OF ENVIRONMENTAL HEALTH -SERVICES FINAL STTE INSPECTION 9 � 7112 — o k Date: Street Location -�N �,friL �iz.4 _ Inspected by �?'l� ,4rr,E�s�l" Permit.0 .. TM# 3dy Subdivision Lot # _4( 1.' Sgwaae Svstem Area a. STS area located as 'per approved pproved plans ..........:...... b.. Fill section date of placement 3:1 barrier Lgth. , ' 'Width Av c. Natural soil not stripped...... d. Stone, brush, etc., greater .than 15' from STS area e. .100' from water course /wetlands ::.................. II. Sewage Svstem _... a. Septic tank sir . , 00 ...:.....1,250......... other...... b. S eptic tank level .......:............... c. 10' minimum -from foundation .......................... d. Distribution Boa . 1. AIt outlets at same elevation- water.tested.... ...... 2-. Protected below frost ................. 3. . winimum 2 ft. Original soil between box & tren e. Jnction Bog properly set....... 6. .......................... ren es 1. Length required Length installed 2. Distance to watercourse measured -V270 Ft..... 3. Installed according to plan . ..:..:......................... 4. Slope of trench acceptable 1/16 - 1./32" /foot...... 5. 10 ft. from .property line - 20 ft.- foundations.... 6. Depth of trench <30 inches from surface............ 7. t Doom allowed for expansion, 100 % ......... :......... 8 . Size of gravel 3/4 - 1 W diameter clean ............ 9. Depth of gravel intrench 12" minim 10. Pipe ends-.capped ............. ....:, gone hr:Ditse�' stcgs- ; 1111 . .......... .......� ....... . _..__ 1. Size of pump chamber ............................................ 2. Overflow tank. ....:..... ...............1.11..1.......:. 4. Pump easily acc sille, manhole to grade........:. . . gr .. 5. First box baffied .:.:...................1111 6. Cycle witnessed by H. D.estimated' flow /cycle. III. House(BuRding a. douse located per approved lans, ..... , b. Number of bedrooms........... P ...........,���r� 1111.. IV. wen well located as per approved plans.......:...,' b. Distance from STS area measured �/1 • ft c. Casing. 18" above grade ........................................... d. Surface drainage around well .acceptable ..... :............ V. ' Overall Workmawhio . a. Boxes properly grouted ... ............................... b. All pipes partially bacldilled ..................................... ......... c. All pipes flush with inside of box ...... ......... d. BackM material contains stones <4" diameter........... e. Curtain drain & standpipes. installed according to pla f. ' Curtain draiii outfall protected & dir,to exist watercc g. Footing drains discharge away from STS area.......... h. Surface water protection adequate....._ ................... i. Erosion control provided ........... ............................... Rev. 12/02 pUTNAM COUNT.' DEPA�2TNM1'�TT Op HEALTJEI _ ........ _ - - -_ ._.MJaSION OP' ENMON MC NTAx,. Al jR. ]E tVICES A -17£ENTION JOSEPH GENE REQUEST FOR. FINAL INSPE ON For: Fill All information must be fully completed prior to any Trenches inspections being made. pCHD Construction permit located: c .� e a y (T) (V) Owner /App licant Name: TM , _._ Block _ Lot Subdivision Name: Formerly: ��� } Subdivision Lot t Is system fill completed? Is system complete? Is system constructed as per plans? Is well drilled? Is well located as per plans? Are erosion control measures in place? -- Date :• Date: Date: I certify that the system(s), as listed, at the above prermses has been constructed and I have inspected and -verified their completion in accordance with the issued PCHD Constriction Permit and approved plans and the Standards, Rules and Regulations of the I utnam County Department of Health. r,. �...._ , , PE C _ , �,eitificd by. .... , De professional Address: 1" p i3D S A Jo lJ Lie, Comments: ZO/T0 39t1d 9NId33NI9N3 ?GM3dg 66ZSLLV -BTS Lb:ET ZTOZ /50/60 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E. Director of Environmental Health July 31, 2012 Roy Fredriksen, P.E. PO Box 950 Mandpac, NY 10541 Dear Mr. Fredriksen: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MARYELLEN ODELL County Executive Re: Field Inspection — SMG & Gramatan Assoc. Theodore Trail. (T) Patterson, TM 34. -2 -49 The above referenced separate sewage treatment system can be backfilled. The following comment needs to be addressed: • The well needs to be inspected by this Department upon completion. If you have any further questions, please contact me at (845) 808 -1390, ext. 43261. Sincerely, Gene D. Reed Sr. Environmental Health Engineering Aide GDR:cw 07/27/2012 11:02 518- 4775233 BREWER ENGINEERING PAGE 02/02 PX?TNAM COUNTY DEPARTMENT OF HEALTH I)MSION O)F ENVIRONMENTAL IWALTH SERVICES ATTENTION 0 JOSEPH GENE R- U]EST F R FMALL.aS CTION All information must be fully completed prior to any inspections being made. For: Fill Trenches L PCHD Construction Permit # Located: T�21� f `` (T} �) ° - Owner /Applicasat Name: TM Block ^ 2 Lot Formerly: Subdivision Name: � Subdivision Lot # Is system fill completed? - Date: Is system complete? Date: Is system constructed as per plans? Is well drilled? ,,.,� Is Is well located as per plans? Are erosion control measures in place? I certify that the system(s), as listed, at the above premises has been constructed and T haveinspected Mid verified their cozmpletiOn in accordance with the issued FCHD Construction Permit and approved plans and the Standards, Rules and Regulations of the Putnam County Department of .. Health. Date: '7 Certified by: PE � A De Professional 1' and i' / /� U Lic, #�5�t75•- Address: , Comments: Form FIR -99 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PERMIT # ONS "'RUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM -. 5ihg�6,) Located at ![ Ao OChj2.a 1'0-.4 j Town or Village P.9r. go t4 ' >Mq A-3Sec. Subdivision name AA/n-4 -r-*Q j4s� !Q cSubd. Lot # 4 Date Subdivision Approved 9L2-V--0/ If Tax Map Block 2, Lot Renewal Revision — Owner /Applicant Name me-5 -7;je Date of Previous Approval Mailing Address K40 Amount of Fee Enclosed I c oc) n , t4. �'.. Zip f 0-T?8 Building Type Cole4mf— Lot Area 124.No. of Bedrooms 4 Design Flow GPD &00 Fill Section Only Depth Volume PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED Separate Sewerage System to consist of 12-S(3 gallon septic tank and ,5'O 0 !=r 6 � ?- Ir t 0!z 1 '12fi'm; C S. Other Requirements: To be constructed by �119 A Water Supply: Public Supply From Private.Supply. Drilled bil..:__. _ Address Address _... _. . . - - -- =- • -= -. -- -• .... Address.. I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original system or any repairs thereto. Signed: /�� P.E. c/ R.A. Date �Z Address O�C' CU,1� �% /�. �/ (��¢� License # APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the sewage treatment system has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered n cessary by the',Publ'ic Health Director. Any revision or alteration of the approved plan requires a new p it. A proved discharge of domestic sanitary sew a only. By: Title: Date:'�� White copy - HD F ; YCIlow dppy - Building Inspector; Pink copy - Owne ,P ge opy - Design Professional /� l / Form CP -97 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES APPLICATION TO CONSTRUCT A WATER WELL- please print or type Well Location Street Address: Town/Village: Tax Map # . r1ooaote -r— Rill )TrR.9o1•L Map Block 2- Lot(s) Well Owner: Name: 0 K-p Address: Phone #: 914^ Cama 14001e4., P56 i ' in 4144 UK, ,S t kra - Use of Well: residential _Public Supply Air /cond /heat pump _Irrigation 1- Primary Business Farm Test/monitoring —Other(specify) 2- Secondary Industrial Institutional Standby Amount of Use Yield Sought gpm # People Served Est. of Daily usage gal. Replace Existing Supply Test/Observation Additional Supply Reason for Drilling ue<ew Supply (new dwelling) Deepen Existing Well Detailed Reason t,-) Usv- for Drilling Well Type rilled Driven Gravel Other Is well site subject to flooding? Yes _ No Is well located in a realty subdivision? ............................... Yes 6--No ........................................... Name of subdivision q A330 G jig 365 Lot No.� Water Well Contractor: ' a "3,D Address: Is Public Water Supply available on site? ....................................... ............................... Yes No-&,--' Name of Public Water Supply: Town/Village T Distance to property from nearest water main: Proposed well location & sources of contamination to be provided on separate sheet/plan. Date: 3 'z - Applicant Signature: V! .:... PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided that within thirty (30) days of the completion of water well construction, the applicant or their designated representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form provided by the Putnam County Health Departmei ......... .............. . take appropriate action to assure that any and all water and waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be amended or modified when considered necessary by the Commissioner of Health. Any revision or alteration of the approved Ian requires a new permit. Well to be constructed by a water well driller certified by Putnam ou�nty. Date of Issue 4— Permit Is ing Date of Expiration -/ Title: Permit is Non - Transferable White copy - HD file; Yellow copy - Building Inspector; Pink copy - Offer; Orantle copy - Well driller Form WP -97 Rev. 3/06 1\ . Ir u 4 1 A-- 11% PUTNANI COUNTY DEPARTVIENT OF HEALTH DIVISION OF ENVIRONVIENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: 6� w Address: Located at (street ): LG TM 9 Section Blocic 2 Lot Ntunicipalitj . -1 Watershed: ( YlC SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking: Date of Percolation Test: Hole No.. i Run No. Time Start — Stop Elapse Time (min.) Depth to ' water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch 2z 3 . I .0; I l` Z b - 5 ALI, ! 3 4 J r I ! 5 1 I f1: b o 15 s.,� 4 � •LJ J I I C f ! Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < t min For 1 -34 min /inch, < 2 min for 31-60 min: inchi. Alt data to be submitted for review. 2. Depth measurements to be made from top of hole. Fonn DD-9i, og ; or 2 . PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES LETTER OF AUTHORIZATION RE: Property of ki oF-Tq Cou Located at 'J/ 16 O Do IZtL_ 24 T/V f24 ffT 25b N Tax Map # Block 2 Lot 4% Subdivision of 0 1z19 S1-11eq, Subdivision Lot # Filed Map # Date Filed Gentlemen: This letter is to authorize Roy a duly licensed Professional Engineer G6r Registered Architect to apply for the required wastewater treatment and/or water supply pen-nit(s) to serve the above -noted property in accordance with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam County Health Department, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said wastewater tretment and/or water supply systems in conformity.with the provisions of Article 1.45 and/or 147 of the Education Law, the Public Health Law; and the PutnaYmCounty Sanitary Lode. ' "" Countersigned: P.E., R.A., # Mailing Address PC) State tA• _Zip f 0141 Telephone: 5'/6 / 2.4!� 0 26� S' Very truly yours, Signed: of Address: 15'6 1&47A'�%k STS �/Otnwq����Ty State ip Telephone: 2449 -S-3 romi LA -97 a _ PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: Coca nTy YOM6S Located at (street): -0400 Dale E Municipality: EqTrril--gso/ i Addressv, -z Sf yO j&'6w? TM # Section: Block ?- Lot Watershed: i DnLAL ,52 O- AhC SOIL PERCOLATION TEST DATA Witnessed by: %C;`j4e i 13y cj oln sk i Date of Pre - soaking: S' / 2 — / 0 Date of Percolation Test: S —/3 —/!D Hole No. • Run No. Time Start — Stop Elapse Time (min.) Depth to . water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min /inch 1 /O:i o o =2s /3 i5 1 6.0 2 /0-, 2 /6:S1 22 JS 119 3 3 'SE il.,24, 26 / 5' .. 3 5 2 i 0• Z JO Z o 2 /o: 2,9 la37 3 . 3 1poo 11:1,g 16 IV14 zo 3 4 IPa 11,36 a 1 20 S �� 5. I :lf /a 16 31,- 1 2 s /�, //-4 2 1& 4(- 3iv 3 30 /h %Z 2 %z 2 4. r 4c3 2 b 5 o: 14. 2,1 33 4.67 45 17 3 567 Notd � l °%!" 1 - -•Mi .^s f n � d'ar 3 j�� F e- S 7 S Liar " p , y OX 0' O -ss c -s, / Tests to,be..repeat4at same depth until approximately equal percolation rates are 4 .tzbrairiei# eaiF ercolarion test hole. (i.e., < I thin for 1 -30 min/inch, < 2 min for 31 -60 min/inch). ral..daazao -6e submitted for review. 2. Depth measurements to be made from top of hole. Form DD -97, pe I oP'- TEST PIT DATA , DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #-k HOLE # � HOLE # HOLE # HOLE #_ G. L. 0.5' To 1.0' Ye,11,5w 8rh "rte 3 ►'� 2.0' 2.5' 3.0' 3.5' ✓e- B ri 4.0' S4nd gSilr obv4 grl 4.5' � 1 ^ Y-Qce, Q role:! i11l�_ And I SI�f` 5.0' Tr4 GC CiroVeI 5.5' S90 Co G GIBS 6.0' 6.5' 7.0' 7.5 8.0' 8.5' 9.0' 9:5 1.0.0'' Indicate level at which groundwater is encounteredo Indicate level at which mottling is observed Indicate level to which water level rises -after being encountered Deep hole observations made by: Aparn -91'e/ Date 16 o c, �.Lg_p TPST -119Oe;l icy 611361 4-'�s0 G. L-Lp Design Professional Name:�•>Z�P21Ks�i�( Address: Q0 13�,�95�U Signature: Design Professional = Seal Q04. P FREO� 9;, _ 0506 */ PUTNAM COUNTY DEPARTMIrA NT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ - -.... APrLUC A T IO *. TAR . =� 1F.OVt�.L OF PLANS FOUR A WASTEWATER TREATMENT SYSTEM 1. Name and address of applicant: 14 as r4 CoUY7 T�" dg!ges ANC /S-�z rbW 4 /gyp Glk sr u �„ �/ol 2K =Tom 0 �. �iG �� 3 /CLI YC5' 2_..Name.of project: 5-5 i S — L-a7' ¢ 3. Location TN: 4. Design Professional: _ -1Zz, 9. Address: •Qo f3ox• 9'50 - - 6:- Drainage Basin: C)P40- Ole4gth t� 46M C, 1DC41 .... r 7. Type of Pro'eecct,: -" �Private/Residential Food Service Commercial - Apartments Institutional Mobile'Home Park Office Building Realty Subdivision Other (specify) - - --•Is -this project subject to State Environmental Quality Review (SEQR)? Type Status (check one)..:::............... Type I Exempt - _._.__ rype-II Unlisted . tI-1- ...- 9. Is a Draft Environmental Impact Statement (DEIS) required? :.:....................... fi[o 10. Has DEIS been completed and found. acceptable by Lead Agency? ............... 11. Name of Lead Agency - 12. Is this project in an area under the. control of local planning,.-zoning, or other . ............ ...... _ - "- :.._..:._ 13. If so, have plans been submitted to such authorities? --- -1.4.: -Has -preliminary approval been granted by such authorities? Date granted: ZQCD/ 15. Type of Sewage Treatment System Discharge .::.............. surface water ✓'groundwater 16: - If surface water discharge, what is the stream class designation? .................... . 17.. Waters index number (surface) ........................................... ............................... 18. Is project located near a public water supply system? ....... ............................... Flo 19. If yes; name of water supply ^- Distance to water supply.- - 20. Is project site near - a public.sewage collection-or treatment system? ................ 21. Name of sewage system. -- Distance °to sewage system , 22-. :Date test holes observed 6-/2--/o 23. Name of Health Inspector M/K-- J3U 6lnslc r' 24: Project design flow (gallons per day) ........ .................... ............... .. 3,0 0,... . 25. Is State Pollutant Discharge Elimination _ System ( SPDES) Permit required ?... t4 o 26. Has SPDES Application been submitted to local DEC office? Form PC -97 .... . 8/99 27. Is any pQrtipn of this proj.cct located within . a designated Town or State wetland? Nco _.. Edeuaus ID ivuiriber:::....: _. . .......................... ..... ............................... 29 ..Is' Wetlands Permit required? ..... ............................... ........ ............................... Has application been made to Town or Local DEC office? Does project require.a.DEC Stream Disturbance Pe rmit? ................................. ^^ `I MIN 31.. Is or.was project site used for agricultural activity involving application of --pesticides to orchards or other crops, solid or. hazardous waste. disposal, landfilling, sludge application or industrial activity? - -32. Is project located within 1,000 feet of existing or abandoned landfill, . hazardoug''Waste site, salt sfockpile, landfill, sludge disposal site or any other potentially known source of contamination? 33. Is there a local master plan on file with the Town or Village? ............. :...... T --Y-es. _- - - -- 3 .. 7Are community water and/or sewer facilities planned to be- developed within - 15 years in or adjacent to project site?.:: :.:!............................................................ 35-. Are any sewage treatment areas in excess of 15% slope? . ............................... 36. 'Tax Map ID Number .............. ............................... .Map Block 2. Edo ............ Lot T" . 37. Approved plans are to be returned to ..... Applicant t.�esign Professional _ NOTE.- .All.applicatio:is.for re � iew an"' approval of a new SSTS to be located within the NYC Watershed shall be sent to the Department, and need-not be sent in duplicate to the DEP, although the project may require DEP approval ofahe SSTS prior to final approval by the Department. Projects within the watershed may also require DEP review and approval of other aspects. of a project, such as stormwater plans or the creation of im gryious.surfaces, and the project applicant should obtain the-appropriate forms for such activities from - DEP and submit.those forms to DEP for review and approval. If the. application is signed by a person other than the applicant shown in Item 1.'the application must be accompanied by a Letter of Authorization (Form LA -97). Failure to comply with this provision may be grounds for the rejection of any submission. I herehy affrrj�r, under penally of perjury, that information provided on this form is true - to the hest of my Imowledge and belief. FaLse statements made herein are punishahle as !a Class A rnisdemeanor pursuant to, ection 210.45 f the Penal Law. - SIGNATURF_S - & ®FFICIAI: •TITISS 00 -1 .,61134 1161 L3 C) 9, S0 Mailing Address: ................................... REBECCA WTl°1'ENBE1tG, RN, BM PublieHeaM Director r Director of m' * mneWd Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 April 6, 2012 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Roy Fredriksen, P.E. P.O. Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: MARYELLEN ODELL CowllyFarcrrtt�e Re: Complete Application Determination for North Country Homes Inc. Lot #4 - SMG Assoc. (T) Patterson, T.M. 34 -2-49 Middle Branch Reservoir Basin The Putnam County Department of Health (Department) has determined that the above referenced application, including fee, and revisions received by this Department on April 4, 2012 is complete. The Department will notify you by April 26, 2012 of its determination. .19 The Project has been delegated to the Putnam County Health Department for review pursuant to the guidelines set forth in the Watershed Agreement. ❑ Joint review with the NYCDEP will commence pursuant to the guidelines set forth in the Watershed Agreement. _.:., -_,. _ _. _ .._......._..: If +he.DPpar nest fails t ^- rotif,, ; -v ceu �;mr e fi ne; yuu may nnuiy tire- ,-- ............... Department of its failure by certified mail, return receipt requested. The notice should be sent to my attention at the above address. This notice must include your name, the location of the project, the office with which you filed the application originally, and a statement that a decision x is sought in accordance with section 18 -23 (d) (6) of the NYC Dept. of Environmental Protection Watershed Rules and Regulations. If the Department fails to notify you within 10 .days of the receipt of the notice, your application will be deemed approved, subject to standard terms and conditions as set forth in the regulations. Please be advised that projects within the NYC Watershed may also require Department of Environmental Protection review and approval of other aspects of a project, such as stormwater plans or the creation of impervious surfaces, and the project applicant should contact the Department of Environmental Protection regarding such activities to see if Department of Environmental Protection review and approval is required. If you have any questions regarding this matter, please call me at (845) 808 -1390 ext. 43148. R pectfuL "ichael Director of MJB:cw WS2 REBECCA WIT TENBERG, RN, BSN Public Health Director . Director of Environmental Health DEPARTMENT OF HEALTH 1 Geneva Road,.Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 MLARYELLEN ODELL County Executive TO: NYCIDEP DEPARTMENT OF ENGINEERING AND DESIGN REVIEW ATTN: FROM: PROJECT: DELEGATION STATUS FOR SUBSURFACE SEWAGE TREATMENT SYSTEM PROGRAM DELEGATED New Application [ Renewal ❑ i Alf, LOCATION: '7/f&oAD4 -7p—Af L- TOWN: DATE SUB'D APPROVAL TM # 34 NOTICE OF COMPLETE APPLICATION DATE: DELEGATED Roy. A. lFredriksM P. Consulting Engineer PO Box 950 Mahopac, NY 10541 (518) 928-0265 (cell) Putnam County Health Dept. 1 Geneva Road Brewster, NY 10509 ATT: Mr. Michael Budzinski, PE Dear Mr. Budzinski: March 28, 2012 RE: North County Homes, INC Lot No. 4 Theodore Trail (T) Patterson TM 34-2-49 We received your letter of March 20, 2012 and have addressed your comments as follows: 1. We have completed the soil data sheet with my seal and signature. 2. Note #1 was corrected to reflect the &te of the percolation test as May 13, 2010. 3. A north arrow was added to the location map. Very Truly Yours, Roy A. Fredriksen REBECCA MMG, RN, BSN Public Health Director -.. Director ofEmkonmedal Health DEPARTAIEII T . OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845 808 -1390 March 20; 2012 Fax # (845) 278 -7921 Roy Fredriksen, P.E. P.O. Box 950 Mahopac, NY 10541 Dear Mr. Fredriksen: MARYELLEN ODELL County Faecuttve Re: Incomplete SSTS Application Determination for North Country Homes Inc. (Lot #4 — SMG Assoc. & Gramaton Assoc. RS) (T) Patterson, T.M. 34 -2 -49 The Putnam County Department of Health (Department) has determined that the above referenced project, which was received by the Department on March 15, 2012 is incomplete. Please be advised that the following information is required to be submitted before the Department can determine the application complete and commence its review: i/1 • An originally completed soil data sheet with the design engineer's signature and seal. Note #1 on the site plan is to be revised to reflect the correct date of the _ ._..:- .__._..._percolation - tests: -- ., _. - _ .... ..... ..... _....__..._.- _- .....: _._.._ __._._.._., _...., _ _....__.. -, . A north arrow is to be provided on the location map. Review of your application will commence once the Department receives the requested information and determines that the application is complete. The Department will notify you within 10 days of its receipt of the requested information as to the completeness of your application. Please be advised that failure to submit information to the Department or to follow procedures is sufficient grounds to deny approval, pursuant to the New York City Department of Environmental Protection Watershed regulations and Putnam County Department of Health Regulations. Should you have any questions or care to discuss this matter further, please contact me at (845) 808 -1390, ext. 43148. Respectfully, Michael J. Director of MJB:cw Gbo 470 O ` � v A (aA �a —,Oo LO\ IGkp� pp. �1 1 I � O Ex /ST v� �L i S ,O tv s D��e �laS 0 \ ,O:-r, AG"' / MANUFAUIUMpU SILT FENCE DETAIL S ICT _ — _. .T.S. N.T.S. A B CAPAl' L,__ WID1H IN 1250 c1AL� •••IB' t Gbo 470 O ` � v A (aA �a —,Oo LO\ IGkp� pp. �1 1 I � O Ex /ST v� �L i S ,O tv s D��e �laS 0 \ ,O:-r, AG"' /